When you read between the lines of the healthcare reform law, its general intent becomes clear: The law is about increasing home- and community-based services (HCBS), and improving wellness and prevention.
The law reflects and continues the national trend of keeping people at home and in the community, and away from nursing homes. Some examples:
—The Community Living Assistance Services and Supports (CLASS) Act. A “class”-ic example of this concept, it encourages people to stay at home with a cash benefit if they develop two or more disabilities. Another purpose of the act is to help cushion Medicaid, which would most likely end up paying for those who cannot afford to stay at home. (FYI: I have mentioned that people can choose to opt into the plan. In fact, they have to opt out, as workers, such as you and I, are automatically enrolled in the program.)
—Under the Community First Option, states can cover community-based attendant services to Medicaid beneficiaries with disabilities if the beneficiaries otherwise would require hospital or nursing home care.
—States also can provide more types of HCBS to individuals with higher levels of need through the option of a state plan amendment rather than through waivers. This provision could change the long-term care landscape, as states have until now had to attain permission from the government through waivers to offer HCBS.
The pursuit of wellness is another goal of the law, as the provision creating “medical homes” illustrates:
—The law creates a program to establish and fund community health teams to support the development of medical homes for people with chronic conditions. The program will increase access to comprehensive, community-based, coordinated care. States have the option of enrolling Medicaid beneficiaries with chronic conditions in these homes.
—Also, the law provides coverage under Medicare for an annual wellness visit and personalized prevention plan services.
Eliminating unnecessary hospitalizations is another intent of the new law.
—The pilot program for bundling is an example of this. It encourages hospitals, doctors and post-acute providers to improve patient care and achieve savings for Medicare through bundled payments. A demonstration project will study the use of bundled payments for hospital and physicians services under Medicaid.
Keep in mind there is “good bundling” and “bad bundling,” as a long-term care policy expert recently told me. Nursing homes have been opposed to the idea of allowing hospitals to keep the payments for distribution. But they are keen on the idea of better coordination of care between healthcare entities.
My general sense of the law is it is taking a long-range view of long-term care. Lawmakers acknowledge that baby boomers are aging and want to head off a possible crash of the already-strained Medicaid system, which ends up caring for those who cannot pay for long-term care.
As part of this general view, it regards the long-term field as a continuum of care that begins in a person’s home. It is targeting wellness and prevention as a way to avert hospitalizations and nursing home stays.
Such ideas are praiseworthy. To the extent they will work is still unclear. Nursing homes still play a major and pivotal role in the healthcare system. To disregard their place in the system is naïve.
Long-term care, take a seat
I have written frequently in the last year about how long-term care desired a place at the healthcare reform table, so to speak. It is clear that it found a place in the law.
While major problems, such as Medicaid underfunding and a troubled survey and certification process for nursing homes, still demand attention, there are glimmers of hope. Here are a couple other examples that I have not previously mentioned:
—A provision called “Sense of the Senate Regarding Long-Term Care” recommends that during the 111th Congress, Congress should address long-term services and supports in a comprehensive way, in the community as well as in institutions. (You can’t get more long-term care-oriented than this.)
—Another is a plan to develop a Federal Coordinated Health Care Office within the Centers for Medicare & Medicaid Services to more effectively integrate benefits under Medicare and Medicare. It aims to improve the quality of health and long-term care services of dual eligibles, who make up a large portion of nursing homes residents. One of its specific responsibilities is supporting state efforts to coordinate and align acute and long-term care services for dual eligibles.
To wit: This office is different from the Center for Medicare & Medicaid Innovation, which the new law also establishes within CMS. The purpose of the Innovation Center is to research and test new payment and delivery arrangements to improve quality and reduce the cost of care in each program.
No question, there is still a ways to go to improve long-term care and the system governing nursing homes specifically. But the healthcare reform law acknowledges that long-term care is a part of the healthcare system—and not a neglected step-child.
